CHEST Guidelines-Perioperative Management of Antithrombotic Therapy

Perioperative Management of Antithrombotic Therapy

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The American College of Chest Physicians released guidelines on managing antithrombotic therapy for patients undergoing elective surgeries. This guideline addresses various patient scenarios based on anticoagulant or antiplatelet therapy types, particularly focusing on four categories: those on vitamin K antagonists (like warfarin), direct oral anticoagulants (DOACs), and antiplatelet drugs, including management considerations around elective procedures, interruptions, and heparin bridging.<br /><br />Key recommendations include:<br />1. Avoiding heparin bridging for patients with atrial fibrillation and mechanical heart valves, suggesting bridging only for those at high risk for thromboembolism.<br />2. Continuing VKA therapy for certain procedures, like pacemaker implantation.<br />3. Structured guidelines for perioperative management of patients taking DOACs suggest a standard interruption period before surgeries, differing by drug type and surgery risk.<br />4. Recommendations against routine use of perioperative coagulation function testing for patients on DOACs.<br />5. Advice on managing patients with antiplatelet therapy, suggesting continued aspirin use unless there's a high risk of bleeding, while advising stopping P2Y12 inhibitors before surgeries.<br />6. Guidance for managing antithrombotic therapy in minor procedures to minimize disruption or changes in therapy, balancing bleeding risk with thromboembolic protection.<br /><br />Despite new insights since previous guidelines in 2012, uncertainties persist around best practices for many perioperative management questions. The guidelines emphasize individual risk assessment and practical management strategies without replacing professional medical care. A corrigendum in July 2023 refined thromboembolic and bleeding risk classifications initially presented, reinforcing the importance of integrating clinical judgment with guideline-based recommendations.

Keywords

antithrombotic therapy

elective surgeries

vitamin K antagonists

direct oral anticoagulants

heparin bridging

atrial fibrillation

mechanical heart valves

antiplatelet therapy

perioperative management

clinical judgment